Last October, in 48 hours of chaos, the pounds 1.5m computer-aided dispatch system at the London Ambulance Service collapsed. Calls disappeared, others were picked up by an answering machine, more than one ambulance arrived at the same incident and others took several hours to turn up. A second computer failure within 10 days forced operators to revert to pen and paper.
The report said managers had rushed ahead with the 'high risk' strategy of installing a system that was incomplete, with known technical problems, which had not been tested and had insufficient back-up. Staff were not trained properly to use a system which was imposed by an over-zealous and misinformed management.
The ambulance service, following regional health authority guidelines, appeared to have opted for the cheapest system with little regard for whether it was best suited, the inquiry concluded.
The report said LAS managers were under enormous pressure to succeed. 'This may have blinded them to some of the fundamental difficulties with the (computer) system that perhaps in retrospect seem rather more obvious.'
Union leaders said up to 20 deaths resulted from the computer crash - an allegation hotly contested by management. Yesterday's document shied away from linking deaths directly with the delays. It said an examination of 26 cases at coroners' courts since November 1991 showed the service had not been blamed for a death. Two cases are outstanding.
Mr Harris, whose resignation takes effect from Monday, apologised for the management's failings: 'We caused a considerable amount of anguish to the people of London - something which they had no right to expect from the LAS.'
He said that his stepping aside would clear the way for the review of management, pointing out that decisions by John Wilby, the former chief executive, led to last October's crisis. 'He was the chief executive at the time. He endorsed the system, it is no part of a non-statutory body to overrule that decision.'
Professor Marion Hicks, chairman of South West Thames regional health authority, revealed that the region and ambulance managers had already decided to move Mr Wilby out of his post when the computer collapsed. She said the crash effectively pre- empted that, since it prompted Mr Wilby to resign. Mr Harris added that it would be unfair to place all the blame on one man.
The remaining board members refused to discuss their positions yesterday. Officials of the National Union of Public Employees said that the rest of the board, due to meet today, should go.
Virginia Bottomley, Secretary of State for Health, yesterday promised a fundamental review of accountability within the service, demanding proposals within a month from the regional health authority. She admitted misleading MPs last October but shrugged aside Labour calls that she and her junior health minister, Tom Sackville, should also resign.
Her suggestion then that difficulties emerged 'because there had been an excessive number of calls' was 'not strictly accurate,' she told the Commons. She blamed the information she had been given. The system was designed to deal with 2,300 emergency calls a day.
Mrs Bottomley claimed there had been 'significant improvements' in the service since the autumn, although response times remained 'well below' cities outside London.
Union leaders said the latest official figures show that during January, on average 64 per cent of ambulances arrived within 14 minutes of a call. The figure for last December was 59 per cent, while for November it was 61 per cent. The Government's standard - as laid out in the Patient's Charter - is 95 per cent.
On average, 76 per cent of ambulances arrived within the target time during 1990, Nupe said. That fell to 66 per cent over 1991 and to 58 per cent for 1992 (excluding October, the month of the computer breakdown, for which figures have not been released).
Union officials said they had pointed out problems with the service continuously over the past two years. Stuart Barber, Nupe's ambulance officer, said that he had tried on 12 separate occasions to meet board members and regional managers, but his requests were rejected.
Union leaders demanded that the 147 vacancies within the service be filled immediately, and an extra 100 ambulance staff be taken on. Extra funding was also needed straight away.